Routine inspection·May 1, 2025

On 5/1/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a annual required inspection visit. LPA Allen met with Richard Pacheco- Maintenance Director who was informed of the purpose of the visit. The facility is an RCFE licensed for 128 non-ambulatory residents and there is an approved hospice waiver for 10. The facility is a four story structure located in a residential neighborhood. There are c urrently 56 residents residing in the facility. The physical plant consists of the following: ninety-two (92) resident rooms with attached bathrooms. There is a dining area, kitchen, garage, library, activity room, gym, front garden with two outdoor covered areas in with tables and chairs. At 9:50 AM - 11:22 AM LPA toured the physical plant with Richard Pacheco- Maintenance Director. There were no bodies of water or obstructions on the premises. LPA inspected a total of seven (7) bedrooms and seven (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. During the inspection Amanda Monroy-Administrator arrived and continued with assisting with the inspection. The bathrooms were in good condition and operational. The water temperature ranged from 105°F to 118. °F, and the bedroom temperatures ranged from 72°F to 78°F the facility appeared to be clean, sanitary, and appropriately furnished. LPA observed cleaning supplies / toxins stored in the house keeping closet inaccessible to residents. The kitchen was inspected, and there was a 5 day supply of perishable food items and a 7 day of non-perishable food items which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 4/30/2025. At 11:35 AM LPA also reviewed seven (7) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings which were all current with the exception of three (3) staff files reviewed did not have the required first aid/CPR certifications up to date. Training will be conducted on 5/2/2025. At 12:45 PM, LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans which were up to date. LPA also conducted a random audit of 6 residents medication administration records (MARS) which appeared that medications are being administered as prescribed by their physicians. Based on the observations made during today’s visit, a Technical Advisory was issued for not having 3 of the 6 staff members first aid/CPR certifications up to date. An exit interview was conducted, and this report was discussed and provided Amanda Monroy- Administrator at the conclusion of the visit.